ADHERENCE TO PRESCRIBED EXPLICIT CRITERIA DURING UTILIZATION REVIEW -AN ANALYSIS OF COMMUNICATIONS BETWEEN ATTENDING AND REVIEWING PHYSICIANS

Context.-Utilization review (UR) seeks to improve quality and cost-eff iciency of health care. However, how well the process works in practic e has not been assessed. Objective.-To describe the outcomes of a samp le of physician reviews in terms of the explicit criteria that the UR was designed to implement. Design.-Retrospective analysis of transcrip ts of precertification reviews. Participants and Setting.-California p hysicians employed by a UR firm conducted 96 interviews from April 199 0 to July 1991 with attending physicians who had proposed to insert ty mpanostomy tubes on a patient younger than 16 years and whose proposal s had been found to be inappropriate on an initial screen. Main Outcom e Measures.-The appropriateness rating assigned to each case by the ph ysician-reviewer and by the investigators using explicit criteria. Log istic regression identified factors associated with the reviewers' rec ommendations to perform surgery and with recommendations at variance f rom the criteria. Results.-The reviewers recommended 78% of cases for surgery, of which only 29% were supported by the criteria or had exten uating circumstances. The criteria. concurred with all 30 of the revie wers' recommendations against surgery. Two factors, female sex (odds r atio [OR], 8.2; 95% confidence interval [CI], 1.2-53.8) and previous t ympanostomy tube insertion (OR, 30.9; 95% CI, 2.4-394.8) were associat ed with reviewer recommendations in favor of surgery that were at vari ance from the criteria, despite the lack of evidence for either as a m itigating circumstance. Conclusion.-Physician reviewers were more leni ent than the explicit criteria that the reviews were designed to imple ment. In no cases did the reviewers depart from the criteria's recomme ndations in favor of surgery.